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But relative to whites, minorities continue to suffer
illness and death disproportionately and this dispro-portionate
suffering has not been appreciably altered in
the recent past. Unintended pregnancies (as measured by
abortions and teenage pregnancies, especially repeat
teenage pregnancies) continue to be a major problem in
the minority community, with racial gaps recently
stabilizing or worsening rather than improving. While
reductions have occurred in the minority infant death
rate, it is still almost twice the white rate. Similarly, while
minorities have experienced greater declines in overall
mortality than whites in the recent past, they still have
death rates at least 40% higher. The major contributors to
the disparity are homicides, cancer (particularly prostate,
stomach, cervical, and lung cancers), all other accidents,
cerebrovascular disease, nephritis/nephrosis, and chronic
liver disease/cirrhosis. Using a somewhat conservative
definition* of "excess" mortality (i.e., the ratio of the two
highest race-sex-specific rates), rates for these causes were
at least 50% higher for either minority males or minority
females than the next highest rate. Of these two race- sex
groups, minority males are clearly the group most at risk
of excess death and, consequently, most in need of
interventions to lower this risk.
Although not included in the above listing because of
the conservative definition, hypertension and diabetes are
significant contributors to the health problems of
minorities, although in a different way. Mortality ratios
by sex show that minorities are at least twice as likely as
whites to die from these causes. However, mortality
statistics based on underlying cause of death underestimate
the magnitude of these problems because their contribu-tion
to other health problems such as heart disease,
stroke, and diseases of the kidney and eyes are not
quantified. For example, in 1985 hypertension was the
underlying cause on 231 death certificates but was
mentioned on 4,126 (8% of total certificates). Of
certificates with hypertension mentioned on them, heart
disease was also mentioned on 79%, atherosclerosis on
31%, and cerebrovascular disease on 30%. Diabetes was
the underlying cause on 869 certificates but was mentioned
on 4,130 (8% of total). Of these, heart disease was
mentioned on 75%, atherosclerosis on 40%, and
cerebrovascular disease on 23%. Both diabetes and
hypertension were mentioned together on 947 certificates
(about 1.8% of total certificates). Consequently,
hypertension and diabetes are not themselves major
killers based on underlying causes of death but contribute
to the severity of other problems which take an excessive
toll on minorities.
Given the disproportionate illness and death of
minorities, can we account for such disparities? Numerous
factors are presumed to influence health, and among
these, sociodemographics are believed to be especially
significant ( 1 ). Minorities tend to be less well educated
and to have lower incomes than whites, thereby limiting
access to and knowledge of health services and healthy
practices. The income problem is exacerbated by the fact
that minority families are generally larger than white
families and are more likely to be female-headed.
Combined with the aforementioned problems, minorities
are more likely to be concentrated in urban areas and thus
are exposed to a relatively greater number of environmental
hazards including pollution, traffic hazards, substandard
and overcrowded housing, and crime. Because of the
lower levels of education, minorities tend to be relegated
to positions that potentially present greater levels of
exposure to environmental risks such as physical and
mental stressors and toxic substances. Where these
socioeconomic factors affect health status, differentials in
health can be expected.
The differentials in socioeconomic status raise another
issue in accounting for racial disparities in health—that is,
the appropriateness of "race" as a comparison variable.
The term "race" connotes genetic differences, but in
actuality is a more powerful force in determining health
not for biological but for social reasons (8). In analyzing
race differentials, it would have been preferable to
compare affluent whites with affluent minorities and the
white poor with the minority poor to better delineate
whether the health differentials are due to economic
differences. Differential income levels within and among
racial groups act as confounding variables and distort any
overall racial comparisons. This problem was clearly
demonstrated when, using education as a proxy for
income, comparisons were made of adequacy of care, low
birthweight, and neonatal and postneonatal mortality by
race and education. With these indicators, for example,
minority health tended to improve significantly as
socioeconomic status increased, but the gaps between the
minority and white rates widened, illustrating the con-founding
of income, health status, and race. Unfortunately,
in most cases, North Carolina data collection systems do
not exist that enable the analysis of data by income.
Yet, even among the limited comparisons of race, education
and infant health, the comparability of groups is still an
issue. For example, among births under 2500 grams,
minorities have had a lower neonatal death rate than
whites, regardless of education. One suggested explanation
'This was considered a conservative approach because with some causes, minorities had the two highest race-sex-specific rates. For these causes, while
there were significant differences if we compared the minority and white rates by sex, there was little difference when comparing the male and female
rates by race.
12

But relative to whites, minorities continue to suffer
illness and death disproportionately and this dispro-portionate
suffering has not been appreciably altered in
the recent past. Unintended pregnancies (as measured by
abortions and teenage pregnancies, especially repeat
teenage pregnancies) continue to be a major problem in
the minority community, with racial gaps recently
stabilizing or worsening rather than improving. While
reductions have occurred in the minority infant death
rate, it is still almost twice the white rate. Similarly, while
minorities have experienced greater declines in overall
mortality than whites in the recent past, they still have
death rates at least 40% higher. The major contributors to
the disparity are homicides, cancer (particularly prostate,
stomach, cervical, and lung cancers), all other accidents,
cerebrovascular disease, nephritis/nephrosis, and chronic
liver disease/cirrhosis. Using a somewhat conservative
definition* of "excess" mortality (i.e., the ratio of the two
highest race-sex-specific rates), rates for these causes were
at least 50% higher for either minority males or minority
females than the next highest rate. Of these two race- sex
groups, minority males are clearly the group most at risk
of excess death and, consequently, most in need of
interventions to lower this risk.
Although not included in the above listing because of
the conservative definition, hypertension and diabetes are
significant contributors to the health problems of
minorities, although in a different way. Mortality ratios
by sex show that minorities are at least twice as likely as
whites to die from these causes. However, mortality
statistics based on underlying cause of death underestimate
the magnitude of these problems because their contribu-tion
to other health problems such as heart disease,
stroke, and diseases of the kidney and eyes are not
quantified. For example, in 1985 hypertension was the
underlying cause on 231 death certificates but was
mentioned on 4,126 (8% of total certificates). Of
certificates with hypertension mentioned on them, heart
disease was also mentioned on 79%, atherosclerosis on
31%, and cerebrovascular disease on 30%. Diabetes was
the underlying cause on 869 certificates but was mentioned
on 4,130 (8% of total). Of these, heart disease was
mentioned on 75%, atherosclerosis on 40%, and
cerebrovascular disease on 23%. Both diabetes and
hypertension were mentioned together on 947 certificates
(about 1.8% of total certificates). Consequently,
hypertension and diabetes are not themselves major
killers based on underlying causes of death but contribute
to the severity of other problems which take an excessive
toll on minorities.
Given the disproportionate illness and death of
minorities, can we account for such disparities? Numerous
factors are presumed to influence health, and among
these, sociodemographics are believed to be especially
significant ( 1 ). Minorities tend to be less well educated
and to have lower incomes than whites, thereby limiting
access to and knowledge of health services and healthy
practices. The income problem is exacerbated by the fact
that minority families are generally larger than white
families and are more likely to be female-headed.
Combined with the aforementioned problems, minorities
are more likely to be concentrated in urban areas and thus
are exposed to a relatively greater number of environmental
hazards including pollution, traffic hazards, substandard
and overcrowded housing, and crime. Because of the
lower levels of education, minorities tend to be relegated
to positions that potentially present greater levels of
exposure to environmental risks such as physical and
mental stressors and toxic substances. Where these
socioeconomic factors affect health status, differentials in
health can be expected.
The differentials in socioeconomic status raise another
issue in accounting for racial disparities in health—that is,
the appropriateness of "race" as a comparison variable.
The term "race" connotes genetic differences, but in
actuality is a more powerful force in determining health
not for biological but for social reasons (8). In analyzing
race differentials, it would have been preferable to
compare affluent whites with affluent minorities and the
white poor with the minority poor to better delineate
whether the health differentials are due to economic
differences. Differential income levels within and among
racial groups act as confounding variables and distort any
overall racial comparisons. This problem was clearly
demonstrated when, using education as a proxy for
income, comparisons were made of adequacy of care, low
birthweight, and neonatal and postneonatal mortality by
race and education. With these indicators, for example,
minority health tended to improve significantly as
socioeconomic status increased, but the gaps between the
minority and white rates widened, illustrating the con-founding
of income, health status, and race. Unfortunately,
in most cases, North Carolina data collection systems do
not exist that enable the analysis of data by income.
Yet, even among the limited comparisons of race, education
and infant health, the comparability of groups is still an
issue. For example, among births under 2500 grams,
minorities have had a lower neonatal death rate than
whites, regardless of education. One suggested explanation
'This was considered a conservative approach because with some causes, minorities had the two highest race-sex-specific rates. For these causes, while
there were significant differences if we compared the minority and white rates by sex, there was little difference when comparing the male and female
rates by race.
12